Acute Pain services ( APS ) nurses training program

1. Acute Pain services ( APS ) nurses training program

2. Objectives • Have an understanding of pain , pathophysiology ,assessment and pain assessment tools • Have understanding the adverse affects of untreated severe pain • Have a knowledge of pain relief delivery modalities , analgesic drugs and side effects of drugs . • Have an understanding the protocol , leaflets and questionnaire that is in practicing in Adan Hosp.

3. Definition of Acute Pain “Pain is an unpleasant sensory and emotional experience associated with actual or potential tissue damage or described in terms of such damage.” IASP (1979) • Implies emotional component. • Pain can exist without tissue damage.

4. Descriptions of PainCategories of Pain by Duration Acute Pain Brief duration, goes away with healing, usually 6 months or less. Due to traumatic ,or acute illness ,or surgery . Chronic Pain Which is cancer and non cancer pain

5. Nociceptive pain Neuropathic pain Idiopathic pain Psychogenic pain Commensurate with identifiable tissue damage May be abnormal, unfamiliar pain, probably caused by dysfunction in PNS or CNS Pain, not attributable to identifiable organic or psychologic processes Sustained by psychologic factors Pathophysiology

6. Categories of Pain by Type Somatic Source: Skin, muscle, and connective tissue Examples: Sprains, headaches, arthritis Description: Localized, sharp/dull, worse with movement or touch Pain med: Most pain meds will help, if severe, need a stronger medication

7. Categories of Pain by Type Visceral Source: Internal organs Examples: Tumor growth, gastritis, chest pain Description:Not localized, refers, constant and dull, less affected with movement Pain Med: Stronger pain medications

8. Categories of Pain by Type Neuropathic Source: Nerves Examples: Diabetic neuropathy, phantom limb pain, cancer spread to nerve plexis Description:Burning, stabbing, pins and needles,shock-like, shooting Pain Meds:Opioates+tricyclic antidepressants or other adjuvant

9. Idiopathic Pain • Pain in the absence of an identifiable physical or psychologic cause • Pain is perceived to be excessive for the extent of organic pathology

11. Consequences of Untreated PainWhat happens if pain isn’t properly treated? • Respiratory-decreased cough and lung volume, atelectasis, sputum retention,infection, hypoxaemia • Cardiovascular- tachycardia, hypertension, increased myocardial oxygen consumption, myocardial ischaemia, deep vein thrombosis • Gastrointestinal - decreased gastric and bowel motility • Genitourinary- urinary retention

12. Neuroendocrine - increase in levels of catecholamines, cortisol, glucagon, growth hormone, vasopressin, aldosterone and insulin • Psychological - anxiety, fear, lack of sleep • Musculoskeletal- muscle spasm, immobility(increasing risk of deep venous thrombosis)

13. Predictors of acute pain leading to chronic pain • Poorly controlled acute pain • Pre operative pain • Intensity of acute post op pain • Amount of opioids consumed in period after surgery

15. Key role of nurses in POP management Among all health professionals, nurses spend the most time with patients in pain.

16. Pain Assessment “One of the most important functions of the nurse is to alleviate the suffering of people who are experiencing pain” Schofield P(1995)

17. Why assess pain ? • To establish degree and nature of pain • To ensure patient comfort • To evaluate effectiveness of analgesia • To help alleviate anxiety • To decide on type of analgesia • To aid recovery and prevent complications

18. How to assess pain • Communication with patient is essential • Observe for changes in physiological signs • Use a pain scoring system : 1)VAS 2)faces pain scale (Advantageous with language barriers. Sensitive 3)NRS 4) VRS • Consider pain as 5th vital sign

20. OPQRST Pain Assessment Method • O(Onset) When does the pain start? Does it come and go? • P(Provacation/Pallitation) *What were you doing when the pain started? *What caused it? *What makes it better? worse? • Q(Quality/Quantity)*What does it feel like? Is it sharp? dull? stabbing? burning? crushing? throbbing? nauseating? shooting? twisting? stretching? • R(Region / Radiation) *Where is the pain located? *Does the pain radiate (i.e. spread to another location, e.g., pain source is from thumb but pain spreads to elbow)?* Where does it radiate? Is it all in one place? Does it go anywhere else?

21. OPQRST Pain Assessment Method: CONT. • S (Severity/Scale) How severe is the pain on a scale of 0 - 10, zero being no pain at all and 10 being the worst pain ever? Does it interfere with activities? How bad is it when it's at its worst? Does it force you to sit down, lie down, slow down? How long does an episode last? • T(Timing) When did the pain start, at what time? How long did it last? How often does it occur? Is it sudden or gradual? What were you doing when you first experienced or noticed it? How often do you experience it: hourly? daily? weekly? monthly? When do you usually experience it: daytime? night? in the early morning? Are you ever awakened by it? Does it lead to anything else? Is it accompanied by other signs and symptoms? Does it ever occur before, during or after meals? Does it occur seasonally?

22. Factors influencing pain response: -Past experience -Anxiety and depression -Culture -Age -Gender -Placebo effect: occurs when a person responds to a medication or other treatment because of an expectation that the treatment will work more than that actually do. It results from the natural production of endorphins in the descending control system.

23. Analgesic Ladder

24. POP treatment modalities/delivery techniques • Nonopioid analgesics • Opioids • Local anaesthetics

25. POP treatment modalities/delivery techniques • 1)NSAIDs :A) Oral non opioid: brufen diclofenac indomethacin B) IV non opioid: Perfalgan Contraindication : *Renal disease * CHF *Allergy * coagulopathy *peptic ulcer *BA *Pt.receivingSSRIs

26. 2) Opioid: A) IV opioid : * Morphine * Pethadine *Tramadol Contraindications:* Acute Respiratory Depression or COPD *Risk of pralyticileus B) Oral opioid: * Tramadol Contraindications:*Risk of seizer activity * Renal compramise * Pt. receiving SSRIs

27. Adverse effects of opioids • Respiratory Depression • Sedation • Nausea and Vomiting • Pruritus • Urinary retention • Hallucinations

28. 3) Local anaesthetics • Lidocaine • Bupivacaine • Ropivacaine Side effects and pharmacological treatment: • Hypotension: - replace intravascular volume with crystalloid or colloid. - adrenergic agents (phenyl ephrine and ephedrine). • Sensory block

29. Numbness to light touch: - ↓ conc. of local anesthetic in the epidural infusion. • Motor block. - in 2 – 3% of patients receiving epidural analgesia. - resolves in most cases after stopping infusion for 2 hrs but persistent or ↑motor block must be evaluated. Spinal hematoma or abscess must be considered.

30. Delivery techniques of POP treatments : • PCA • Epidural analgesia • Peripheral nerve blocks • Intrathecal drug delivery ( IDD )

31. 3)Epidural Analgesia • Is one of the most effective methods available for the management of acute pain

32. ANATOMY • Outside dural sac but inside vertebral canal • Contains spinal nerve roots, areolar tissue, fat, arteries and a plexus of veins • It is a discontinious space • Epidural space ends at the sacral hiatus

33. Epidural Anatomy

34. Epidural Advantages • Improved pain control • Decreased length of hospital stay • Increased gut motility • Less overall opioiduse

35. Epidural Complications • Postdural puncture headache (PDPH) • Back pain at insertion site • Catheter migration/ displacement • Epidural abscess • Epidural hematoma • Aseptic mennigitis • Unexplained neurological damage (transient neurologic syndrome) • Non working

36. Indications & contraindications • Indications: • • Major surgery • • High risk patients. • Contraindications: • • Patient refusal • • Untrained staff • • Coagulopathy • • Local or systemic sepsis • • Hypovolaemia / dehydration • • Mechanical difficulty with insertion • • Neurological deficit

37. Observations • Frequency should be dictated by local guidelines and the needs of the • individual patients. • • Blood pressure: invasive / non-invasive • • Heart rate / pulse • • Sedation level • • Respiratory rate • • Oxygen saturation • • Pain assessment • • Assessment of sensory level • • Assessment of motor block • • Nausea • • Pruritis • • Inspection of epidural insertion site • • Infusion of device checks. • Postoperative Pain Management

38. Typical epidural catheter label

41. 4) PCA: Patient Controlled Analgesia (PCA) is the self-administration of an analgesic within safe limits as prescribed by an Anesthesiologist on the Acute Pain Service or an ordering Physician .

42. Indications & containdication • Indications : • Requirement for parenteral analgesia • • Patients with a high opioid requirement • • Unpredictable opioid requirements. • Contraindications: • • Patient / carer refusal • • Cognitive impairment • • Inability to operate the handset • • Untrained medical and nursing staff • • Extremes of age.

43. PCA Advantages • Improved pain control • Decreased demand on nursing time; less time preparing injections • Decreased risk of needle stick injuries • Rapid onset of analgesia • Ability to rapidly administer analgesic prior to mobilization • Preservation of self control • Less tissue damage due to injections • Ease of breathing and coughing, improved respiratory function • Increased satisfaction with pain management • PCA eliminates the waiting period in a typical post-operative pain cycle • PCA also eliminates wide fluctuations (peak and trough effects of plasma analgesic drug concentration).

44. Complications of PCA: • Side effects R/T the opioid • ( nausea/vomiting , pruritus , respiratory depression , urinary retention , confusion , hypotension , decreased bowel motility ) • Complications R/T equipment , staff or pts. • Equipment malfunction • Staff error • Inappropriate pt. or non pt. use

45. Adverse Effects • • Increased sedation • • Respiratory depression • • Nausea • • Pruritis • • Urine retention • • Hallucinations / confusion. • In the following patients,cautionshould be exercised, and dosage ofdrugmay need to be reduced: • • Elderly patients • • Patients with renal impairment • • Patients with liver failure • • Head injury patients.

46. Observations: • • Sedation level • • Respiration rate • • Oxygen saturation • • Blood pressure: invasive / non-invasive • • Heart rate / pulse • • Pain assessment • • Nausea • • Pruritis • • Inspection of infusion site • • Infusion device checks.

47. عزيـــــزي الزائـــــر يُسمَـــح للمريـــض فقـــط باستعمالهـــا Dear Visitors Only the PATIENT is allowed to push the button

48. Pain Sedation Call for Nurse Nurse variables Pain Relief PCA Nurse Responds Patient Variables Absorption from site Screening Sign out Medication Administer Med. Prepare Medication